A Dual Hospital-University Specialist Training Reform to Address Workforce Shortage and Geographic Maldistribution in Indonesia: Integrative Qualitative Policy Process Review.

Background: Indonesia faces 3 interlocking medical workforce crises: an absolute specialist deficit projected to reach 70,000 by 2032 (national density of 0.18 per 1000 population vs the Ministry of National Development Planning [Bappenas] target of 0.28), severe maldistribution (with nearly 59% of specialists concentrated in Java), and a structural anomaly in which residents pay tuition while performing essential clinical work. The 2023 Health Law (Law 17/2023) authorized a transformative reform: a hospital-based residency pathway (Rumah Sakit Pendidikan Penyelenggara Utama [primary teaching hospital; RSPPU]) operating in parallel with the long-established university-based system. Objective: This study aimed to examine the rationale, policy design, and early implementation of Indonesia's dual hospital-university specialist medical education reform, interpreted through an 8-step change management framework developed by Kotter, and to identify transferable lessons for low- and middle-income countries. Methods: We conducted an integrative qualitative policy process review combining two evidence streams: (1) systematic documentary analysis of 19 source documents (17 primary legal, regulatory, and policy instruments plus 2 interministerial joint monitoring site-visit reports) and (2) engagement of 34 key informants through semistructured interviews and focus group discussions (45-120 min), comprising policymakers, collegium representatives, hospital leaders, and residents across all 6 pilot sites, recruited purposively until thematic saturation. Interview and focus group data were analyzed using a hybrid deductive-inductive thematic approach with an 8-step change management framework developed by Kotter as an a priori coding frame, and member checking was completed with 7 of the 34 informants. Results: The reform designated 6 top-tier national referral hospitals as RSPPUs and enrolled 52 residents from 412 applicants (an acceptance rate of 12.6%) across 6 high-need specialties (ophthalmology, cardiology, pediatrics, orthopedics, neurology, and oncology). All 6 pilot sites established functional education units and designated institutional officials, adopted dual accreditation, and operationalized an integrated e-logbook for competency tracking, real-time monitoring of 80-hour duty limits, and anonymous bullying reporting. An interministerial joint monitoring team visited all 6 sites and scored each site as satisfactory or better across governance, curriculum, faculty, infrastructure, and learner support. Four cross-cutting themes emerged: financial-barrier removal, dual-governance pragmatism, accreditation strain, and equity-anchored deployment. Persistent tensions include variable educator compensation across hospitals; however, a standardized national framework remains under development. Mapping to the framework developed by Kotter demonstrated strong evidence for steps 1 to 6 and early evidence for steps 7 to 8. Conclusions: Indonesia's dual hospital-university residency model is a scalable, equity-oriented, and competency-based reform that is operationally feasible and globally aligned in its early implementation. While long-term effectiveness and sustainability await longitudinal evaluation, the design offers a transferable, not yet definitively replicable, template for low- and middle-income countries confronting parallel workforce crises.